CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107

CHAPTER 4: THE FOUR (4) P’S

COMPONENTS OF LABOR STRUCTURE OF THE FETAL SKULL

• A successful labor depends on four integrated concepts: • The cranium, the uppermost portion of the skull, comprises
1. The PASSAGE (the woman’s pelvis) eight bones (important in childbirth):
2. The PASSENGER (the fetus) o 4 superior bones
3. The POWERS (uterine factors) 1. The frontal (two fused bones)
4. The PSYCHE (the woman’s view) 2. Two parietal
1. PASSAGE 3. The occipital
• Refers to the route a fetus must travel from the uterus through
the cervix and vagina to the external perineum.
• Because the cervix and vagina are contained inside the pelvis,
a fetus must pass through the bony pelvic ring.
• The pelvis must be of adequate size.
• 2 pelvic measurements are important to determine the
adequacy of the pelvic size:
a. The diagonal conjugate (the anterio-posterior diameter of
the inlet)
b. The transverse diameter of the outlet
THE PELVIC INLET

• At the pelvic inlet, the anteroposterior diameter is the

narrowest diameter (12.5 cm)
THE PELVIC OUTLET

• At the outlet, the transverse diameter is the narrowest (11 cm)
• If a disproportion between the fetus and pelvis occurs, the
pelvis is the structure at fault.
• When an infant cannot be born vaginally, emphasize that it is
the pelvis that is too small, not that the head is too big.
2. PASSENGER
• The passenger is the fetus
• The body part of the fetus that has the widest diameter is the
HEAD, so this is the part least likely to be able to pass through
the pelvic ring.
• Whether a fetal skull can pass or not depends on both its
structure (bones, fontanelles, and suture lines) and its
alignment with the pelvis.
o The other four bones of the skull lie at the base of the
cranium
o They are of little significance in childbirth because they
are never presenting parts
1. Sphenoid
2. Ethmoid
3. Two temporal bones
o The bones of the skull meet at suture lines
o The suture lines are important in birth because, as
membranous interspaces, they allow the cranial bones to
move and overlap, molding or diminishing the size of the
skull so that it can pass through the birth canal more
readily.
FONTANELLES
• Membrane-covered spaces found at the junction of the main
suture lines
1. ANTERIOR FONTANELLE (BREGMA)
• Lies at the junction of the coronal and sagittal sutures
• Fusion of 2 frontal bones and 2 parietal bones making the
anterior fontanelle diamond-shaped

LAMAGON | BSN 2A
 CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107
CHAPTER 4: THE FOUR (4) P’S

2. POSTERIOR FONTANELLE
• Lies at the junction of the lambdoidal and sagittal sutures
• Because the two parietal bones and the occipital bone are
involved at this junction, the posterior fontanelle is triangular
• Smaller than the anterior fontanelle

FETAL PRESENTATION AND POSITION

• Two other factors play a part in whether a fetus is lined up in
the best position to be born
1. ATTITUDE
• Describes the degree of flexion a fetus assumes during labor or
the relation of the fetal parts to each other
A. Good attitude
- Is in complete flexion
- The spinal column is bowed forward
- The head is flexed forward so much that the chin
touches the sternum
- The arms are flexed and folded on the chest
- The thighs are flexed onto the abdomen
- And the calves are pressed against the posterior
aspect of the thighs
B. Moderate flexion
- If the chin is not touching the chest but is in an alert
or “military position”
C. Partial extension
- Presents the “brow” of the head to the birth canal
D. Poor flexion
- The back is arched, the neck is extended, and a fetus
is in complete extension presenting the
occipitomental diameter of the head

• Fontanelle spaces compress during birth to aid in molding the

fetal head
o Their presence can be assessed manually through the
cervix after it has dilatated during labor
o This helps establish the position of the fetal head and
whether it is in a favorable position for birth
o The space between the two fontanelles is referred to as
the vertex
o The area over the frontal bone is referred to as the
sinciput; occipital bone is occiput
MOLDING
• Is the change in the shape of the fetal skull produced by the
force of uterine contractions pressing the vertex of the head
against the not-yet-dilated cervix causing the bones of the
fetal skull to overlap and cause the head to become narrower
and longer.
• Only lasts a day or two

LAMAGON | BSN 2A
 CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107
CHAPTER 4: THE FOUR (4) P’S

2. ENGAGEMENT TYPES OF CEPHALIC PRESENTATION

• Refers to the settling of the presenting part of a fetus far
enough into the pelvis to be at the level of the ischial spines, a
midpoint of the pelvis.
• The degree of engagement is assessed by vaginal and cervical
examination.
• A presenting part that is not engaged is said to be “floating”
• A presenting part that is descending but has not yet reached
the ischial spines is called “dipping”

3. STATION
• Refers to the relationship of the presenting part of a fetus to
the level of the ischial spines.
• When the presenting part is at the level of the ischial spines, it
is at 0 station (synonymous with engagement)
• If the presenting part is above the spines, the distance is
measured and described as minus stations, which range from -1
to -4 cm.
• If the presenting part is below the ischial spines, the distance
is stated as plus stations (+1 to +4 cm)
• At a +3 or +4 station, the presenting part is at the perineum
and can be seen if the vulva is separated (crowning)
2. BREECH PRESENTATION
• Means that either the buttocks or the feet are the first body
parts that will contact the cervix.
• Breech presentations occur in approximately 3% of births and
are affected by fetal attitude.
• Breech presentations can be difficult births, with the presenting
point influencing the degree of difficulty
• It can be complete, frank, and footling.
TYPES OF FETAL POSITION
• Refers to the relationship of the presenting part to a specific
quadrant of a woman’s pelvis.
• Position is indicated by an abbreviation of three letters:
1. Middle letter denotes the fetal landmark
2. First letter defines whether the landmark is pointing to
the mother’s right (R) or left (L).
3. Last letter defines whether the landmark points anteriorly
(A), posteriorly, (P), or transversely (T).

4. FETAL LIE
• Is the relationship between the long (cephalocaudal) axis of
the fetal body and the long (cephalocaudal) axis of a woman’s
body
• Horizontal (transverse) or vertical (longitudinal)
• Approximately 99% of fetuses assume a longitudinal lie
TYPES OF FETAL PRESENTATION
1. CEPHALIC PRESENTATION
• Most frequent type of presentation (95%)
• The fetal head is the body part that will first contact the cervix

LAMAGON | BSN 2A
 CARE OF MOTHER, CHILD, ADOLESCENT | NCM 107
CHAPTER 4: THE FOUR (4) P’S

DILATION
• Enlargement of the cervical os from an orifice a few
millimeters in size to an aperture large enough to permit the
passage of a fetus (diameter about 10cm)

MECHANISMS OF LABOR 4. PSYCHE

(DEFIRE ERE) • The 4th “P” or Psyche, refers to the psychological state that a
• Descent woman brings into labor.
• Engagement • For many women, this is a feeling of apprehension or fright.
• Flexion • For almost everyone, it includes a sense of excitement or awe.
• Internal rotation
• Extension
• External Rotation
3. POWERS OF LABOR
• Supplied by the fundus, are implemented by the uterine
contractions, a process that causes cervical dilatation and then
expulsion of the fetus from the uterus
• Phases of Contraction:
A. Increment
B. Acme
C. Decrement

UTERINE CONTRACTION

CERVICAL CHANGES
EFFACEMENT
• Shortening and thinning of the cervical canal from a structure
1 or 2 cm in length to one in which no canal at all exists, except
a circular orifice with almost paper-thin edges

LAMAGON | BSN 2A